Every finding on record at Waters of Indianapolis, The

Based on interview and record review, the facility failed to protect a resident's right to be free from sexual abuse for 1 of 3 residents reviewed for abuse. A male resident was observed leaving a female resident's room. The female resident indicated the male resident touched her breast. (Resident B, Resident C) Findings include:On 12/30/25 at 9:09 a.m., the Director of Nursing (DON) provided a copy of a facility reportable incident, dated 12/5/25 at 12:30 p.m. A review of the reportable incident brief description indicated Resident C made an allegation that Resident B touched her breast.During an interview on 12/31/25 at 8:15 a.m., Resident C was unable to describe the details of a sexual abuse allegation that she made against Resident B. Resident C repeated the word fine after each question of the interview. The clinical record for Resident B was reviewed on 12/31/25 at 9:02 a.m. The diagnoses included, but were not limited to, Alzheimer's disease, hemiplegia that affected his right side, and diabetes.An annual Minimum Data Set (MDS) assessment, dated 9/27/25, indicated Resident B was moderately cognitively impaired.A care plan, dated 12/5/25, indicated Resident B exhibited sexually inappropriate behavior of touching and grabbing toward a cognitively impaired resident that lacked the ability to consent.A nursing communication form, dated 12/5/25 at 12:30 p.m., indicated Resident B exhibited sexually behaviors. Resident B had been placed on one-on-one observation and his medication had been reviewed.The clinical record of Resident C was reviewed on 12/31/25 at 9:49 a.m. The diagnoses included, but were not limited to, hemiplegia, aphasia (a communication disorder affecting speaking), dementia, and contracture of her right hand.A quarterly Minimum Data Set (MDS) assessment, dated10/7/25, indicated Resident C was moderately cognitively impaired.A progress note, dated 12/5/25 at 1:33 p.m., indicated Resident C had been sent to the emergency department due to physical aggression from another resident.During an interview on 12/31/25 at 10:32 a.m., RN 1 indicated she was the nurse caring for Resident C, on 12/5/25, when Resident C made an allegation of sexual abuse against Resident B. CNA 1 reported to RN 1 that she heard Resident C yelling no, so CNA 1 entered Resident C's room. Resident B was in her room and was escorted out and back to his room which was just across the hallway from Resident C's room. When RN 1 entered Resident C's room, she observed Resident C lying in bed with the left side of her brief unfasted. Resident C indicated to RN 1 that a man entered her room and touched her then pointed at her breast. Since Resident C's brief was unfastened, RN 1 asked if Resident B touched her anywhere else other than her breast and Resident C indicated no. This was the first time RN 1 had ever been made aware of any abuse allegations made against Resident B.During an interview on 12/31/25 at 10:42 a.m., CNA 1 indicated, on 12/5/25 at approximately 11:00 a.m., she was at the nurse's station and heard Resident C yelling out. As CNA 1 was walking toward Resident C's room, she observed Resident B wheeling out of Resident C's room and he indicated he had gotten lost. CNA 1 instructed Resident B that he was not supposed to be in a female resident's room. When CNA 1 entered Resident C's room, she observed Resident C lying in bed with the sheet pulled approximately halfway down the bed, her gown was pulled up, and her brief was unfastened on the left side and bent approximately halfway down in the front. CNA 1 thought this was suspicious because she had just changed Resident C's brief and repositioned her in bed. CNA 1 left Resident C as she found her and immediately went to get RN 1 so she could observe exactly what CNA 1 observed. When CNA 1 returned to Resident C's room with RN 1, Resident C was observed with the sheet pulled approximately halfway down the bed, her brief unfastened on the left side and bent approximately halfway down in the front. There had been no changes in the way Resident C had been observed by CNA 1 initially. When RN 1 asked Resident C if she had been touched, Resident C was unable to verbalize what had happened but was able to point at her breast.On 12/30/25 at 9:09 a.m., the DON provided a copy of a facility policy, titled Abuse Prevention Program, dated 10/22/22, and indicated this was the current policy used by the facility. A review of the policy indicated it was the policy of the facility to prevent abuse.This citation relates to Intake 2686747.3.1-27(a)(1)

Based on interview and record review, the facility failed to ensure a full description of an allegation of sexual abuse was reported to the state health department for 1 of 3 residents reviewed for abuse. A male resident was observed leaving a female resident's room. The female resident was found lying in her bed with the sheet pulled down, her brief unlatched on one side and bent down in the front, and her gown pulled up. (Resident B, Resident C) Findings include:On 12/30/25 at 9:09 a.m., the Director of Nursing (DON) provided a copy of a facility reportable incident, dated 12/5/25 at 12:30 p.m. A review of the reportable incident brief description indicated Resident C made an allegation that Resident B touched her breast.During an interview on 12/31/25 at 8:15 a.m., Resident C was unable to describe the details of a sexual abuse allegation that had been made against Resident B. Resident C repeated the word fine after each question of the interview. On 12/31/25 at 8:30 a.m., the DON provided a copy of a written statement from CNA 1, dated 12/5/25 at 11:50 a.m. (approximately 1 hour prior to the facility reportable incident being submitted), and indicated this was a written statement regarding the allegation of sexual abuse made by Resident C against Resident B. A review of the written statement indicated CNA 1 was at the nurse's station when she heard Resident C yelling. As CNA 1 was walking toward Resident C's room, she observed Resident B wheeling out of Resident C's room. CNA 1 asked Resident B why he was in Resident C's room and educated him that he should not be in a female resident's room. When CNA 1 walked in Resident C's room, Resident C's gown was pulled up, sheet off of her, and brief was open. CNA 1 immediately got RN 1. During an interview on 12/31/25 at 10:32 a.m., RN 1 indicated she was the nurse caring for Resident C, on 12/5/25, when Resident C made an allegation of sexual abuse against Resident B. CNA 1 reported to RN 1 that she heard Resident C yelling no, so CNA 1 entered Resident C's room. Resident B was in her room and was escorted out and back to his room which was just across the hallway from Resident C's room. When RN 1 entered Resident C's room, she observed Resident C lying in bed with the left side of her brief unfasted. Resident C indicated to RN 1 that a man entered her room and touched her then pointed at her breast. Since Resident C's brief was unfastened, RN 1 asked if Resident B touched her anywhere else other than her breast and Resident C indicated no. During an interview on 12/31/25 at 10:42 a.m., CNA 1 indicated, on 12/5/25 at approximately 11:00 a.m., she was at the nurse's station and heard Resident C yelling out. As CNA 1 was walking toward Resident C's room, she observed Resident B wheeling out of Resident C's room and he indicated he had gotten lost. CNA 1 instructed Resident B that he was not supposed to be in a female resident's room. When CNA 1 entered Resident C's room, she observed Resident C lying in bed with the sheet pulled approximately halfway down the bed, her gown was pulled up, and her brief was unfastened on the left side and bent approximately halfway down in the front. CNA 1 thought this was suspicious because she had just changed Resident C's brief and repositioned her in bed. CNA 1 left Resident C as she found her and immediately went to get RN 1 so she could observe exactly what CNA 1 observed. When CNA 1 returned to Resident C's room with RN 1, Resident C was observed with the sheet pulled approximately halfway down the bed, her brief unfastened on the left side and bent approximately halfway down in the front. There had been no changes in the way Resident C had been observed by CNA 1 initially. When RN 1 asked Resident C if she had been touched, Resident C was unable to verbalize what had happened but was able to point at her breast. On 12/30/25 at 9:09 a.m., the DON provided a copy of a facility policy, titled Abuse Prevention Program, dated 10/22/22, and indicated this was the current policy used by the facility. A review of the policy indicated allegations of abuse must be reported.This citation relates to Intake 2686747.3.1-28(c)

Based on observation and interview the facility failed to provide a safe and comfortable environment when the bathroom wall heater covers were removed leaving the metal heating elements exposed for 3 of 3 random observations; and failed to ensure the bathroom door frames were free from rust and decay for 2 of 3 random observations. Findings include:1. During a random observation of the secured memory care unit, on 7/21/25 from 8:25 a.m. until 9:05 a.m., observed the bathroom wall heaters in rooms H-8, H-10, and H-11. Each of the bathroom wall heaters were approximately six inches from the floor. The front cover of the heaters had been removed, which left approximately 40 small silver metal discs lined in a row across the inside of the heater exposed. During an interview, on 7/21/25 at 12:00 p.m., the Maintenance Supervisor indicated the heaters were still in working order and the heating elements should not have been left exposed to the residents. 2. During a random observation of the secured memory care unit, on 7/21/25 from 8:25 a.m. until 9:05 a.m., observed the bathroom door frames from inside the bathrooms of rooms H-10 and H-11. The door frame of room H-10's bathroom was metal with rusted areas on the left side of the frame. The frame had rusted away from the floor up approximately three inches, which left rusted jagged edges at the bottom of the rusted area toward the floor. The bathroom door frame of room H-11 had rusted areas on the right side of the frame. The frame had rusted away from the floor up approximately two inches, which left rusted jagged edges at the bottom of the rusted area toward the floor. During an interview, on 7/21/25 at 12:00 p.m., the Maintenance Supervisor indicated the bathroom door frames should not have been left rusted away. On 7/21/25 at 2:30 p.m., the facility was unable to provide a policy regarding the bathroom wall heaters or the rusted door frames. This citation relates to Complaint 1323958 3.1-19(f)

Based on observation, interview, and record review, the facility failed to ensure dietary staff's facial hair was covered to prevent exposure to food and drinks while in the kitchen for 1 of 2 observations. This had the potential to affect 63 of 63 residents residing in the facility who received food from the kitchen. (Dietary Aide 2) Finding includes: During a kitchen observation on 6/22/25 from 11:40 a.m. to 12:45 p.m., the following was observed: - Dietary Aide 2 was observed in the kitchen near the prepared foods that were uncovered on the steam table. Dietary Aide 2 was observed to have facial hair on his chin approximately one fourth inch in length and was observed scooping ice from the ice machine into glasses, pouring drinks from a pitcher to be served to the residents. Dietary Aide 2 was not observed to be wearing beard net. During an interview on 6/22/25 at 12:45 p.m., the Dietary Manager indicated that staff's hair should be covered when in kitchen. During an interview on 6/22/25 at 1:04 p.m., the Assistant Director of Nursing indicated that hair nets should be worn when around food or drinks. On 6/22/25 at 1:14 p.m., the Assistant Director of Nursing provided a copy of Food Safety & Sanitation, Policy: Employee Health & Personal Hygiene dated 4/2017, and indicated it was the current policy in use by the facility. A review of the policy indicated, Policy # 2, Procedure . Hair restraints will be worn at all times. Beards should [be] well-trimmed and covered with an appropriate hair restraint, . On 6/22/25 at 2:00 p.m., a review of the Indiana Food Establishment Sanitation Requirements, Title 410 IAC 7-24, effective November 13, 2004, indicated, (b)food employees shall wear hair restraints, such as hats, hair coverings or nets .that are designed and worn to effectively keep their hair from contacting .exposed food . 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review, the facility failed to ensure the facility was free from accident hazards for 1 of 1 observation, potentially affecting 13 of 19 self-mobile cognitively impaired residents residing in the Memory Care Unit. An electrical cord was observed on the floor in the middle of a walkway area that was used by the residents. (Resident 29) Finding includes: During an observation of the Memory Care Unit on 6/23/25 from 9:00 a.m. to 9:10 a.m., the following was observed: - The Floor Technician was using an electric buffer/scrubber (buffer) machine on the floor space between rooms [ROOM NUMBERS]. The machine's yellow colored electric cord was approximately one inch in circumference and was approximately 20 feet in length. The cord was observed to be plugged into the hallway outlet located near room [ROOM NUMBER]. As the Floor Technician used the buffer machine, he was observed moving from one side of the hallway to the other side of the hallway as he made his way from room [ROOM NUMBER] toward room [ROOM NUMBER]. The machine's electric cord was observed lying in the middle of the hallway and at multiple points the cord was curled up against itself causing it to be raised above the floor approximately eight to ten inches. No caution signs were visible in the area. - Resident 29, who resided in room [ROOM NUMBER], was observed walking on the left side of the hallway, had stepped over the electric cord that was lying in the middle of the hall and then walked between the cord and the right side of the hall toward her room. As she approached the back of the Floor Technician, without turning or looking at the resident or the electric cord's location, the Floor Technician instructed Resident 29 to just step over the cord! Resident 29 was then observed raising her left foot and then her right foot approximately eight inches high as she stepped over the curled electric cord. - The Floor Technician continued using the buffer without adjusting or moving the electric cord from the middle of hall. - During an interview at that time, the Floor Technician indicated no posted caution sign was required to be visible while he used the buffer machine as the floor was not wet. He generally buffed one side of the hall and then buffed the other side of the hall. The machine's electric cord, approximately 20 feet in length, was to be kept near the wall as opposed to lying in the middle of the hallway because the Memory Care Unit had lots of residents who constantly walk the floors. - During an interview at that time, LPN 3 indicated the electric cord should not be left in the middle of the hall and a caution sign should have been posted in the area while the floor was being buffed. On 06/23/25 at 10:52 a.m., Resident 29's clinical record was reviewed. The diagnosis included, but was not limited to, dementia. The Quarterly Minimum Data Set (MDS) assessment, dated 6/12/25, indicated Resident 29 was moderately cognitively impaired. A review Resident 29's Care Plan, dated 3/13/20, included, but was not limited to, .Resident was at risk of falls related to weakness and medications . On 6/24/25 at 10:03 a.m., the Administrator provided a copy of the resident list which indicated 13 of 19 residents residing on the memory care unit were cognitively impaired and self-mobile. During an interview on 6/23/25 at 1:45 p.m., the Regional Director of Operations indicated the facility did not have a policy for the prevention of accidents or potential hazards. 3.1-45(a)(1)

Based on observation, interview, and record review, the facility failed to ensure the person-centered comprehensive care plan was developed for 1 of 21 residents reviewed for care plans. The care plan was not developed for a resident who was at risk for falls and whose preference was to keep the bed in the high position. (Resident 42) Finding includes: On 6/22/25 at 10:22 a.m., Resident 42 was observed resting in bed. The bed was located next to the wall with the resident's right side near the wall. Resident 42's bed was observed to be in the highest position and was approximately 40 inches above the floor. The handheld bed control device was observed on the bed and within reach of the resident. No staff were visible in the area during that time. During an interview at that time, Resident 42 indicated she was able to adjust the height of the bed and she liked it in the highest position. On 6/22/25 at 12:33 p.m., Resident 42 was observed resting in bed while eating her noon meal. The bed was located next to the wall with the resident's right side near the wall. Resident 42's bed was observed to be in a high position and was approximately 35 inches above the floor. The handheld bed control device was observed on the bed and within reach of the resident. No staff were visible in the area during that time. On 6/22/25 at 1:41 p.m., Resident 42's clinical record was reviewed. The diagnoses included, but were not limited to, vascular dementia and hemiplegia and hemiparesis following a cerebral infarction (stroke with one-sided weakness or paralysis) affecting the right dominant side. The Quarterly Minimum Data Set (MDS) assessment, dated 6/16/25, indicated Resident 42 was severely cognitively impaired. The Fall Risk Review assessment, dated 6/13/25, indicated Resident 42 was at a high risk for falls. Resident 42's person-centered comprehensive care plan, dated 3/3/22, indicated Resident 42 was .at risk for falls related to right sided deficit . Resident 42's person-centered comprehensive care plan failed to address Resident 42's preference for keeping the bed in the high position. During an interview on 6/25/25 at 10:19 a.m., LPN 3 indicated Resident 42 had been educated multiple times on the safety concerns of having the bed in the highest position. For a while now, Resident 42 has continued to adjust the bed to the highest position. During an interview on 6/25/25 at 11:07 a.m., the Assistant Director of Nursing (ADON) indicated Resident 42's clinical record lacked a person-centered comprehensive care plan that addressed Resident 42's preference for keeping the bed in the high position. The ADON indicated Resident 42's care plan should have been developed. On 6/25/25 at 1:45 p.m., the Regional Nurse Consultant (RNC) provided a copy of the Baseline Care Plan Assessment/Comprehensive Care Plans policy, dated 3/23/21, and indicated it was the current policy in use by the facility. A review of the document indicated, .The Comprehensive Care Plans will be reviewed and updated .the facility may need to review the care plans more often based on changes in the resident's condition and/or newly developed health/psycho-social issues . 3.1-35(a)

Based on record review and interview, the facility failed to ensure a medication was administered by qualified personnel for 1 of 19 residents reviewed for medication administration. (Resident B) Finding includes: On 6/24/25 at 1:00 p.m., the Director of Nursing (DON) provided a copy of a facility reportable incident, dated 5/26/25. The incident indicated on 5/26/25, Resident B reported to the facility that on 5/25/25, CNA 8 administered medication that Resident B believed was Tylenol. On 6/24/25 at 1:22 p.m., the Director of Nursing provided a copy of the facility investigation. The investigation included, but was not limited to: The Administrator's written statement, dated 5/26/25, indicated the Administrator had interviewed CNA 8. CNA 8 admitted giving Resident B pills. CNA 8 obtained the tylenol from behind the nurses station and gave them to the Resident B because he did not want the resident to have to wait for the nurse. An email from RN 10, dated 5/26/25, indicated RN 10 had worked on the night of the incident. Resident B was under her care that night. RN 10 was not aware that Resident B was having any pain that night and was unaware that CNA 8 had administered medication to the resident. During an interview on 6/24/25 at 1:33 p.m., Resident B indicated he had a headache on the night of 5/25/25 and turned on his call light to request pain medication. CNA 8 came in to the resident's room in response to the call light. Resident B informed CNA 8 he had a headache. The CNA explained to Resident B that he would get it. The CNA left the room and returned with 2 capsules that were red and gray in color. The resident took the capsules that the CNA brought to him. Resident B then indicated he started to worry and feel funny. The pills did not look like the tylenol he normally received. Resident B reported the incident to the nurse. The nurse called the physician and received orders to send the resident to the emergency room for evaluation and treatment. Resident B indicated the toxicology report from the hospital indicated the medication administered from the CNA was acetaminophen (tylenol). On 6/24/25 at 1:45 p.m., the clinical record of Resident B was reviewed. The diagnoses included, but were not limited to, pain in right knee, pain in left knee, and pain in lower back. An annual Minimum Data Set Assessment, dated 5/29/25, indicated Resident B was cognitively intact. A Physician's Order, dated 4/21/25, indicated Acetaminophen oral tablet 500 mg. Give one tablet by mouth every 4 hours as needed. On 6/24/25 at 1:00 p.m., the Director of Nursing provided a copy of the Certified Nursing Aides job description, dated 4/1/2023. The job description indicated, Position Summary: The Certified Nursing Assistant (CNA) provides each resident with routine daily nursing care and services in accordance with the resident's assessment and care plan with a passionate focus on customer service. Essential Job Functions: A. Role Responsibilities - Care: .Reports all changes in resident's condition to the Nurse Supervisor/ Charge Nurse immediately. On 6/25/25 at 10:47 a.m., the Regional Nurse Consultant provided a document titled Indiana State Department of Health Nurse Aide Curriculum, dated 11/19/15, and indicated it was the current practice of the facility to follow. The document indicated, The nurse aide will perform only the task in the course standards and Resident Care Procedure manual .The Nurse Aide will not administer any medications . This citation relates to Complaint IN00460186. 3.1-35(g)(2)

Based on observation and interview, the facility failed to ensure a treatment cart was securely locked for 1 of 1 random observations. (Faith Hall Treatment Cart) Finding includes: On 6/22/25 from 8:15 a.m. to 8:30 a.m., observed a treatment cart on the Faith Hall to be unlocked and easily opened. No staff were observed in the area. Several residents were sitting in the hall in wheelchairs approximately 4 feet from the cart. The contents of the treatment cart, included but was not limited to: - multiple 0.5 oz tubes of Antifungal cream 2% (used to treat a skin fungus). The label indicated Keep out of reach - multiple 60 gram tubes of Fludocinonide cream 0.05% (used to treat inflammation of the skin). The label indicated Keep out of reach - multiple 1 ounce tubes of gentamicin cream 1%, (used to treat skin infections). The label indicated Keep out of reach. During an interview on 6/22/25 at 8:30 a.m., LPN 3 indicated the cart should have been locked. On 6/23/25 at 2:08 p.m., the Administrator provided a policy titled Medication Storage In The Facility, dated July 2024, and indicated it was the current policy being used by the facility. A review of the policy indicated .3. Medication rooms, carts, and medication supplies are locked or attended by person with authorized access . 3.1-25(m)

Based on interview and record review, the facility failed to implement infection control practices for 2 of 5 residents reviewed for immunizations. The two-step tuberculosis skin test series was not completed. (Resident 15, Resident 58) Findings include: 1. On 6/22/25 at 10:10 a.m., Resident 15's clinical record was reviewed. Resident 15's diagnoses included, but were not limited to, paraplegia (paralysis of the legs or lower body), bipolar disorder (a mental illness characterized by extreme shifts in mood, energy, and activity levels), and chronic osteomyelitis (an infection of the bone). Resident 15 had an admission date of 1/16/25. Resident 15's TB (tuberculosis) test administration history indicated that the resident had an order for a first step TB skin test to be administered 1/17/25 which had been coded on the EMAR (electronic medication administration record) as a 2, which indicated the resident refused the administration. The second step TB skin test ordered for 1/31/25 indicated other/see nurse note. Neither the first step or the second step TB skin test were documented as administered. Resident 15 had a TB screening tool assessment completed on 6/3/25. During an interview on 6/25/25 at 12:45 p.m., the RNC (Regional Nurse Consultant) and the DON (Director of Nursing) indicated that Resident 15 never received a first step or a second step TB skin test; Resident 15 had refused administration of all vaccines and the TB skin test. The RNC and the DON indicated that a resident who refused to have the two-step Mantoux skin test would have a chest x-ray and a TB screening tool assessment done. They each indicated the TB screening tool assessment should have been done at the time of admission or at the time of the resident's refusal to have the TB skin tests administered. 2. On 6/22/25 at 11:20 a.m., Resident 58's clinical record was reviewed. Resident 58's diagnoses included, but were not limited to, congestive heart failure (occurs when the heart doesn't pump enough blood to meet the body's needs), right lower extremity amputation above the knee, and kidney failure. Resident 58 had an admission date of 8/9/24. Resident 58's TB test administration history indicated no administration of a first or a second step TB skin test. Resident 58 had a TB screening tool assessment completed on 6/17/25. During an interview on 6/25/25 at 12:45 p.m., the RNC and the DON indicated that Resident 58 had not received a first step or a second step TB test, and that Resident 58 should have had them administered upon admission. On 6/24/25 at 11:25 a.m., the RNC provided a copy of a Clinical Policy and Procedure titled Tuberculosis Testing Policy and Procedure, dated 1/24/22, and indicated it was the policy currently in use by the facility. A review of the policy indicated, Facility will ensure that all Residents admitted from the community .have completed tuberculosis screening using the two-step method upon hire/admission . 3.1-18(b)(1)

Based on interview and record review, the facility failed to protect the residents' rights to be free from misappropriation of property for 1 of 3 residents reviewed for misappropriation of medications. (Resident C) Finding includes: On 3/21/25 at 9:50 a.m., the clinical record for Resident C was reviewed. The diagnoses included, but were not limited to, Type 2 diabetes mellitus (a chronic condition affecting blood sugar levels). An Admission MDS (Minimum Data Set) assessment, dated 2/7/25, indicated Resident C was cognitively intact. A physician's order, initiated 2/8/25 and discontinued on 3/1/25, indicated Resident C had tirzepatide (an antidiabetic medication used to treat type 2 diabetes and for weight loss) 15 mg (milligrams)/0.5 mL (milliliters) ordered to be given by subcutaneous (under the skin) injection once weekly on Saturdays. A physician's order, initiated on 3/7/25 and with no end date, indicated Resident C had tirzepatide, 15 mg/0.5 mL ordered to be given by subcutaneous injection once weekly on Fridays. During an interview on 3/21/25 at 10:30 a.m., the Administrator indicated on 3/3/25, it had been reported to the former DON (Director of Nursing) by LPN 4 that Resident C had missing insulin medication noted. LPN 4 was in the medication room looking for another resident's insulin medication, and noted that Resident C had only one Mounjaro (tirzepatide) injection in the box and asked if it was the old box. LPN 3 indicated no, that was a new box (the medication boxes come with four pre-filled syringes of the medication dosage at a time) and it should have had only one missing used on Saturday 3/1/25. When the former DON came to check the medication box in the medication room, the one dose that had been there was also missing. It could not be determined by internal investigation who had taken the pre-filled syringes of medication, but the medications were located in the locked medication room behind the nursing station. Only staff members had access to the locked medication room. On 3/21/25 at 11:45 a.m., the Administrator provided a copy of the facility's abuse policy, titled Abuse Prevention Program, dated 10/22/22, and indicated it was the policy in use by the facility. A review of the policy indicated that residents are to be free from abuse, including, but not limited to, misappropriation of resident property. The deficient practice was corrected on 3/19/25 after the facility implemented a systemic plan that included the following actions: the facility inserviced the staff on misappropriation of resident property and ongoing monitoring. This citation relates to Complaint IN00454758. 3.1-28(a)

Based on interview and record review, the facility failed to ensure resident rights were maintained when a cognitively intact resident was not allowed to sign out for a leave of absence for 1 of 3 residents reviewed for resident's rights. (Resident C) Findings include: During an interview on 2/6/25 at 9:42 a.m., Resident C indicated the staff had told her that she cannot sign out and leave the facility for a leave of absence and they had not let her leave. During an interview on 2/6/25 at 1:09 p.m., the Director of Nursing (DON) indicated Resident C was allowed to sign out and leave the facility with family or friends, but not with her boyfriend. Resident C was not allowed to sign out on her own even though she was cognitively intact. The DON did not think Resident C's rights were violated. The clinical record was reviewed on 2/7/25 at 12:13 p.m. The diagnoses included, but were not limited to, alcohol abuse, psychoactive substance abuse, and bipolar disorder. An Admission Minimum Data Set (MDS) assessment, dated 12/25/24, indicated Resident C was cognitively intact. A current physician's order, dated 12/24/24, indicated Resident C may not go out on a leave of absence. There was no stop date noted. On 2/6/25 at 11:44 a.m., the DON provided a copy of an undated facility policy, titled Your Rights and Protections as a Nursing Home Resident, and indicated this was the current policy used by the facility. A review of the policy indicated residents have the right to leave the facility. This citation relates to Complaint IN00451215. 3.1-3(a)

Based on interview and record review, the facility failed to report an allegation of abuse for 1 of 3 residents reviewed for abuse. Staff did not immediately report to the administrator when staff overheard a female resident tell a male staff member she would report him for hitting her and did not accurately report all known information regarding the allegation of abuse at the time the allegation was reported to the state survey agency. (Resident B, CNA 1, CNA 2, DON, Floor Tech) Findings include: During an interview on 2/6/25 at 10:02 a.m., Resident B indicated a couple of weeks ago, in the morning, she was wheeling down the hall and attempted to pass the Floor Technician (Floor Tech), from behind, as he was buffing the floor. The machine was plugged in and the cord was across the floor, and Resident B was on his left. The Floor Tech stuck out his left arm and hit her right shoulder. Resident B said I'm telling that you hit me. Resident B didn't think the Floor Tech. intended to hit her. Resident B couldn't remember the date this happened, but thought it happened between 1/20/25 and 1/22/25. During an interview on 2/6/25 at 10:16 a.m., the Floor Tech indicated, on the morning of 1/22/25, he was buffing the floor when Resident B wheeled the front wheels of her wheelchair over the power cord to the buffer. He told Resident B to back off the cord and as the Floor Tech pulled the cord out of the wall he touched Resident B's hand. The Floor Tech left work until approximately 1:30 p.m., that day until the Director of Nursing (DON) told him he had to leave due to the abuse allegation. During an interview on 2/6/25 at 10:32 a.m., the Director of Nursing (DON) indicated on 1/22/25 at approximately 6:01 a.m., Resident B reported she was going down the hallway and tried to roll over the cord to the buffer as the Floor Tech was buffing the floor. Resident B said the Floor Tech jerked the cord out of the wall and purposely hit her right upper arm. The Floor Tech said he stuck his arm out, so Resident B didn't get hurt. CNA 1 and CNA 2 heard Resident B tell the floor tech she was going to report him for hitting her. The DON wasn't sure if all of that information should have been included in the initial incident report for the state health department because the corporate office had to approve it before they filed it. During an interview on 11:06 a.m., CNA 1 indicated she never heard Resident B tell anyone she would report them for hitting her. CNA 1 was not aware of any incident that occurred with Resident B and the Floor Tech. This was the first time CNA 1 heard anything about any incident between Resident B and the Floor Tech. During an interview on 2/6/25 at 1:24 p.m., CNA 2 indicated when she was standing in another residents bathroom getting ready to provide morning care when she heard Resident B say she was going to report that someone hit her. CNA 2 didn't leave the other resident's room to check on Resident B nor report what Resident B said. CNA 2 should have reported what Resident B said. The clinical record for Resident B was reviewed, on 2/6/25 at 11:32 a.m. The diagnoses included, but were not limited to, bacteremia, acute respiratory failure, and pulmonary edema An admission Minimum Data Set (MDS) assessment, dated 12/18/24, indicated Resident B was cognitively intact and used a wheelchair. On 2/6/25 at 11:42 a.m., the DON provided a copy of a typed document and indicated it was the statements from staff about Resident B's allegation. A review of the document indicated CNA 2 overheard Resident B say that she was going to report him for hitting her. On 2/6/25 at 11:44 a.m., the DON provided a copy of an undated facility policy, titled Abuse Prevention Program, and indicated this was the current policy used by the facility. A review of the policy indicated all employees must promptly report any incident or suspected incident of abuse. On 2/7/25 at 9:20 a.m., the DON provided the reportable incident, dated 1/22/25 at 6:01 a.m., indicated on 1/23/25 the Floor Tech reported to the Administrator that Resident B was going to report him when she tried to pass him this morning, on 1/22/25, as she was going to the pantry, and he was buffing the floors when she tried to pass him and roll her wheelchair over the cord. On 2/7/25 at 2:30 p.m., the facility was unable to provide a policy regarding reporting to the state health department. 3.1-28(c)

Based on interview and record review, the facility failed to follow the abuse policy and ensure an alleged perpetrator of abuse was immediately removed from the facility for 1 of 3 residents reviewed for abuse. (Resident B, Floor Tech, CNA 1, CNA 2) Findings include: During an interview on 2/6/25 at 10:02 a.m., Resident B indicated a couple of weeks ago, in the morning, she was wheeling down the hall and attempted to pass the Floor Technician (Floor Tech), from behind, as he was buffing the floor. The machine was plugged in, the cord was across the floor, and Resident B was on his left. The Floor Tech stuck out his left arm and hit her right shoulder. Resident B said I'm telling that you hit me. Resident B didn't think the Floor Tech intended to hit her. Resident B couldn't remember the date this happened, but thought it happened between 1/20/25 and 1/22/25. During an interview on 2/6/25 at 10:16 a.m., the Floor Tech indicated, on the morning of 1/22/25, he was buffing the floor when Resident B wheeled the front wheels of her wheelchair over the power cord to the buffer. He told Resident B to back off the cord and as the Floor Tech pulled the cord out of the wall he touched Resident B's hand. The Floor Tech left work at approximately 1:30 p.m., that day until the Director of Nursing (DON) told him he had to leave due to the abuse allegation. During an interview on 2/6/25 at 10:32 a.m., the Director of Nursing (DON) indicated CNA 1 and CNA 2 heard Resident B tell the floor tech she was going to report him for hitting her. During an interview 2/6/25 at 11:06 a.m., CNA 1 indicated she never heard Resident B tell anyone she would report them for hitting her. CNA 1 was not aware of any incident that occurred with Resident B and the Floor Tech. This was the first time CNA 1 heard anything about any incident between Resident B and the Floor Tech. During an interview on 2/6/25 at 1:24 p.m., CNA 2 indicated she was standing in another residents bathroom getting ready to provide morning care when she heard Resident B say Resident B was going to report that someone hit her. CNA 2 didn't leave the other resident's room to check on Resident B nor report what Resident B said. CNA 2 should have reported what Resident B said. The clinical record for Resident B was reviewed 2/7/25 at 11:32 a.m. The diagnoses included, but were not limited to, bacteremia, acute respiratory failure, and pulmonary edema An admission Minimum Data Set (MDS) assessment, dated 12/18/24, indicated Resident B was cognitively intact and used a wheelchair. On 2/6/25 at 11:42 a.m., the DON provided a copy of a typed document and indicated it was the statements from staff about Resident B's allegation. A review of the document indicated CNA 1 saw the Floor Tech. and Resident B but did not see an inappropriate interaction. CNA 1 overheard Resident B say she was going to report him for hitting her. CNA 2 did not see an inappropriate interaction but overheard Resident B say she was going to report him for hitting her. During an interview on 2/7/25 at 8:06 a.m., the DON indicated, on 1/22/25 at approximately 6:01 a.m. Resident B told the DON that earlier that morning she wheeled down the hallway and tried to roll over the cord to the buffer as the Floor Tech was buffing the floor. Resident B said the Floor Tech jerked the cord out of the wall and purposely hit her right upper arm. The DON wasn't sure if all of that information should have been included in the initial incident report for the state health department because the corporate office had to approve it before they filed it. During an interview on 2/7/25 at 8:50 a.m., the Administrator indicated the Floor Tech should have stopped and removed himself from the floor. CNA 2 should have stopped what she was doing and ensured Resident B's safety. The Floor Tech should have been removed from the facility at that time. On 2/6/25 at 11:44 a.m., the DON provided a copy of an undated policy, titled Abuse Prevention Program, and indicated this was the current policy used by the facility. A review of the policy indicated separate the alleged perpetrator and ensure all resident's safety. Staff members who are suspected of abuse shall immediately be barred from any further contact with residents and be suspended from duty. 3.1-28(d)

Based on observation, interview, and record review, the facility failed to ensure medications were stored in accordance with accepted professional principles for 2 of 3 residents observed for medication administration. An unlabeled medication was not removed from the medication cart and eye drops were not dated when opened. (Resident D, QMA 1, LPN 1) 1. During a medication pass observation on 2/6/25 at 8:09 a.m., Qualified Medication Aide (QMA) 1 pulled a pill packet out of the medication cart. The packet had the label torn off so there was no resident name, no medication name or strength, and no instructions. Two white round pills with 54/24 on one side of each pill were observed. At that time, QMA 1 indicated the medication packet with the label removed should not have been left in the medication cart because she didn't know who the medication was for, what the medication was, nor the directions. During an interview on 2/6/25 at 10:32 a.m., the Director of Nursing (DON) indicated the medication packet with the label removed should have been removed from the medication cart. On 2/6/25 at 11:44 a.m., the DON provided a copy of a facility policy, titled Prescription Labels, dated 3/2023, and indicated this was the current policy used by the facility. A review of the policy indicated medication containers having damaged labels are returned to the pharmacy. 2. During a medication pass observation on 2/6/25 at 8:46 a.m., Licensed Practical Nurse (LPN) 1 removed the wrapper and opened a new bottle of Zaditor 0.035% eye drops (antihistamine eye drop used to treat itchy eyes) for Resident D. LPN 1 did not date the newly opened bottle before nor after the eye drops were administered. During an interview on 2/6/25 at 10:32 a.m., the Director of Nursing (DON) indicated the bottle of Zaditor eye drops should have been dated when the nurse opened it. On 2/7/25 at 2:30 p.m., the facility was unable to provide a policy regarding dating opened medications. This citation relates to Complaint IN00451215. 3.1-25(j)

Based on observation, interview, and record review, the facility failed to ensure infection control was maintained during the administration of eye drops for 1 of 3 residents reviewed for medication administration. (Resident D, LPN 1) Findings include: During a medication pass observation on 2/6/25 at 8:46 a.m., Licensed Practical Nurse (LPN) 1 carried a bottle of Zaditor 0.035% eye drops (antihistamine eye drop used to treat itchy eyes) into Resident D's room. LPN 1 was not observed to be wearing gloves. LPN 1 explained what she was going to administer and took a pair of clean gloves out of a box and donned the gloves while holding the eye drops. LPN 1 was not observed to perform hand hygiene before donning the gloves. LPN 1 ensured Resident D was sitting up in his chair and leaned his head back, gently pulled down the lower right eye lid, and administered one drop into the outer edge of the right eye and applied pressure for three seconds. Then LPN 1 pulled the left lower eye lid down, administered one drop into the outer left eye and applied pressure for three seconds. LPN 1 asked Resident D if he was okay, removed her gloves, and left the room. No hand hygiene was observed. LPN 1 placed the bottle of eye drops back into the labeled baggy in the top drawer of the medication cart. During an interview on 2/6/25 at 10:32 a.m., the Director of Nursing (DON) indicated the nurse should have washed her hands before she put on gloves to administer Resident D's eye drops. On 2/6/25 at 11:44 a.m., the DON provided a copy of a facility policy, titled Eye Drop Administration, dated 3/2023, and indicated this was the current policy used by the facility. A review of the policy indicated properly wash hands before and after the administration of eye drops. This citation relates to Complaint IN00451215. 3.1-18(b)(1)

Based on interview and record review, the facility failed to protect the resident's right to be free from verbal abuse by a CNA for 1 of 5 resident reviewed for abuse. (CNA 3, Resident B) Finding includes: On 11/14/24 at 9:25 a.m., the clinical record of Resident B was reviewed. The diagnoses included, but were not limited to, cerebral infarction (a reduction of blood flow to the brain), encephalopathy (a brain disorder), and cognitive communication deficit. On 11/14/24 at 9:35 a.m., the Administrator provided a facility reportable incident, dated 10/18/24. The incident indicated that on the previous evening shift, on 10/17/24, CNA 3 spoke to Resident B in an upsetting tone. CNA 3 was suspended pending investigation of the allegations and was terminated the same day after obtaining interviews from Resident B and other witnesses present. During an interview on 11/14/24 at 10:20 a.m., a witness to the 10/17/24 smoking break incident said that CNA 3 was upset about taking the residents out for their evening smoke break because it wasn't CNA 3's assignment. CNA 3 was observed by the witness screaming and yelling at Resident B both inside the building and outside during the actual smoke break, up until they came back inside the building. The witness described that CNA 3 stood on a chair at the nurses' station screaming at Resident B when Resident B asked who would be taking them out to smoke as residents were late for the 6:30 p.m. smoke break. Resident B had asked CNA 3 to stop talking to her and CNA 3 was described as going on and on to Resident B, taunting her and calling her a snitch. The witness described CNA 3 as being very verbally abusive. During an interview on 11/14/24 at 11:50 a.m., the Administrator indicated that CNA 3's behavior on 10/17/24 was not in line with facility policies regarding freedom from abuse. The Administrator indicated that CNA 3 was suspended and then terminated on 10/18/24 after obtaining statements from Resident B and other witnesses. On 11/14/24 at 10:45 a.m., the Administrator provided an undated policy titled Abuse Prevention Program, and indicated it was the current policy in use by the facility. A review of the policy indicated it was the policy of the facility to prevent resident abuse, neglect, mistreatment, and misappropriation of resident property. The policy further includes a description of verbal abuse as, Any use of oral, written [sic] or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, to describe residents, regardless of their age, ability to comprehend [sic] or disability. This citation relates to Complaint IN00445597. 3.1-27(b)

Based on observation, interview, and record review, the facility failed to ensure a self-medication administration assessment was completed for residents with medications left at bedside for 1 of 1 random observations. (Resident 125) Finding includes: During a tour on 5/28/24 at 8:59 a.m., observed Resident 125's room, no staff were observed to be in the room or in hallway. Resident 125 was up in a wheelchair and on top of the bedside table one clear plastic cup filled with six tablets, one capsule, and one gelcap was observed. On 5/29/24 9:30 a.m., Resident 125's clinical record was reviewed. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, alcohol dependence, and anxiety. Resident 125's clinical record lacked a Self-Medication Administration Assessment. During an interview on 5/29/24 at 9:05 a.m., RN 2 indicated medication should not be left unattended in resident rooms. During an interview on 5/31/24 at 8:37 a.m., the Director of Nursing indicated that no medications are to be left in a resident's room. On 5/29/24 at 12:58 p.m., the Director of Nursing provided a policy titled Medication Administration, dated October 2021. A review of the policy indicated, remain with the resident to ensure that the medication is swallowed. The DON indicated that policy provided was currently being followed by facility. 3.1-11(a)

Based on interview and record review, the facility failed to perform safe smoking assessments per facility policy for 1 of 5 residents reviewed for safe smoking. (Resident 1) Findings include: On 5/28/24 at 1:15 p.m., Resident 1's clinical record was reviewed. The diagnoses included, but were not limited to, multiple sclerosis (a disease in which the immune system eats away at the protective covering of nerves causing muscle weakness and problems with coordination), muscle wasting and atrophy, flaccid hemiplegia (paralysis on one side of the body) affecting right dominant side, and unsteadiness on feet. A Quarterly MDS (Minimum Data Set) assessment, dated 3/21/24, indicated Resident 1 had moderate cognitive impairment. The Care Plan included, but was not limited to: Resident 1 is a supervised smoker as evidenced by current smoking assessment and must be supervised during smoking activity, initiated on 8/7/18. The most recent Smoking Risk Assessment in Resident 1's clinical record had an effective date of 9/19/22 and indicated the following for Resident 1: - required the use of a protective apron for smoking breaks. - had a moderate problem with general awareness and orientation, including the ability to understand the facility safe smoking policy. - had a moderate problem with injury potential for causing injury to self or others relating to smoking materials and a moderate problem with history of hazardous behavior related to smoking materials. During an interview on 5/30/24 at 2:25 p.m., the DON (Director of Nursing) indicated that Resident 1 should have had smoking assessments done both quarterly and annually. On 5/29/24 at 12:55 p.m., the DON provided an undated policy titled Smoking Policy, and indicated it was the current policy in use by the facility. A review of the policy indicated under Procedure section 6. Residents will be assessed for safe smoking behavior prior to smoking at the facility. This assessment is found on PCC [Point Click Care]. The resident will be further assessed for smoking, quarterly, annually, after an unsafe smoking episode and after a change of condition.

Based on observation, interview, and record review, the facility failed to ensure pans and cooking utensils were cleaned in a sanitary manner for 2 of 2 kitchen observations. Finding includes: On 11/8/23 at 12:06 p.m., an open meal tray cart was observed. All the meals and drinks were observed to be served in styrofoam boxes and styrofoam cups with plasticware. During an interview on 11/8/23 at 12:09 p.m., RN 1 (Registered Nurse) indicated the facility had been serving meals on styrofoam for a while now. During an interview on 11/8/23 at 12:59 p.m., Dietary Aide 1 indicated the dishwasher had been broken. He indicated if the dietary staff took the time to clean all the silverware, pots and pans, and dishes they wouldn't have the time to make food. At that time, the dishwashing area was observed. Across from the dishwasher, was a 3 compartment sink. Above the sink, was a sign, taped to the wall, that indicated the instructions for using the 3 compartment sink, a detergent dispenser, and a sanitizer dispenser each with a hose that reached down to the sinks. The instructions indicated the first sink compartment was to wash the dishes, the staff should place the hose from the detergent dispenser into the first sink compartment and press the button to dispense the appropriate mix of detergent and water, and food should be scraped off the dishes before submerging the dishes in the water. The second compartment was for rinsing the dishes, did not require any detergent nor sanitizer, and dishes should be submerged in the rinse water until all the detergent is removed, and the third compartment was for sanitizing the dishes, staff should place the hose attached to the sanitizer dispenser into the sanitize sink and press the button to dispense the appropriate mix of sanitizer and water to fill the sink. Each compartment, of the sink, had a sign on the front that indicated what each compartment was used for. The first compartment indicated wash with a line that went across the front of the sink and indicated fill line, the second compartment indicated rinse, and the third compartment indicated sanitize. The first compartment was approximately half filled with two large plastic containers submerged in the water. The hose from the detergent dispenser and the hose from the sanitizer dispenser running into the wash compartment. The second compartment, for rinsing, did not have water but had three large pans sitting in the compartment. The third compartment, for sanitizing, did not have any water but had 3 large metal pans sitting in the compartment. At that time, Dietary Aide 1 indicated the pans were washed in the first compartment and were drying in the rinse compartment and the sanitize compartments. Dietary Aide 1 also indicated he knew one compartment was supposed to have detergent added and one compartment was supposed to have sanitizer added, but wasn't sure which compartment got the detergent nor the sanitizer. Dietary Aide 1 was not sure if the water in each compartment was supposed to be kept at a certain temperature nor the temperature to sanitize pans without sanitizer. During an interview on 11/9/23 at 8:05 a.m., Cook 1 indicated the facility had been serving all meals and drinks in styrofoam for months. At that time, observed the 3 compartment sink. The first compartment (wash compartment) was approximately 1/4 full of bluish water. There were 3 small to medium size metal pans soaking in the water. The second compartment (rinse compartment) was empty. The third compartment (sanitize compartment) did not have any water but had 3 large metal pans sitting in the compartment. A that time, Cook 1 indicated the pans in the third compartment were drying. On 11/9/23 from 8:15 a.m. to 8:22 a.m., observed Cook 1 wash a medium metal pan. Cook 1 turned on the water and pressed the detergent dispenser button to add more water to the first (wash) compartment until the compartment was approximately half full. Cook 1 pulled a medium sized metal pan out of the wash water. The pan had large food particles stuck to the sides of the pan. Cook 1 took a large spoon and scraped the food particles out of the pan and onto the side of the first (wash) compartment. Cook 1 placed the pan back into the first (wash) compartment to wash the pan again. Then, Cook 1 placed the pan into the second (rinse) compartment. Cook 1 turned on the faucet water and sprayed water, out of the faucet, onto the pan and then turned off the faucet water. Once Cook 1 finished spraying the faucet water, Cook 1 pressed the button to dispense the sanitizer and used the hose from the sanitizer dispenser to spray sanitizer water over the pan for approximately 4 seconds. Cook 1 placed the pan in the third (sanitize) compartment. At that time, observed underneath the 3 compartment sink for the detergent and sanitizer. Under the first (wash) compartment was a large blue bag with a small hose that ran from the bag to a connection with the water. Cook 1 indicated the blue solution in the bag was the detergent for the first (wash) compartment. Under the third (sanitize) compartment was a small tube hanging down over a metal rack. The tube was not connected to anything. Cook 1 indicated that was where the sanitizer is supposed to connect to the tube that runs to the sanitize dispenser. Cook 1 walked from the dishwasher area to a storage closet and indicated the kitchen was out of sanitizer and the staff did not know of anywhere else in the facility where the sanitizer would have been kept. Cook 1 was not sure how long the sanitizer dispenser was out of sanitizer. On 11/9/23 at 1:15 p.m., the Administrator provided a copy of an undated facility policy, titled Dishwashing Manual, and indicated this was the current policy used by the facility. A review of the policy indicated each compartment of the 3 compartment sink will be cleaned before each use. The pans will be washed in hot detergent solution in the first compartment, rinsed well in the second compartment, and sanitized in the third compartment by either heat, at least 171 degrees for 30 seconds, or chemicals, according to manufacturers instructions, in the third compartment. The water will be drained when it becomes heavily soiled and refilled. The pans will be drained and air-dried on the drain counter. 3.1-21(i)(2) 3.1-21(i)(3)

Based on observation, interview, and record review the facility failed to protect the resident's right to be treated with dignity for 2 of 3 residents reviewed. Meals were served on styrofoam and residents were wearing two incontinence briefs. (Resident B, Resident C) Finding includes: 1. During an interview on 11/8/23 at 8:24 a.m., Resident B indicated he never requested styrofoam cups. Resident B used the styrofoam cups because that is what the staff gave him. He thought the staff gave him styrofoam because it was quick and easy and it wasn't that important to make sure Resident B had a regular coffee cup with a lid. Resident B would rather have drank coffee out of a regular coffee cup and a handle and lid, but he used the styrofoam because that is what the staff gave him. Resident B was observed to be wearing two incontinent briefs. The brief closest to his skin was soaked with urine. At that time, Resident B indicated he wasn't sure how long the brief had been wet, but thougt it was last changed, around 4:00 a.m., and Resident B believed staff put two briefs on him so they didn't have to worry about it so much. During an interview on 11/8/23 at 9:26 a.m. CNA 1 (Certified Nursing Assistant) indicated the staff should not have applied two briefs on Resident B. The residents were not supposed to wear two briefs. Resident B had told the staff not to put two briefs on him. During an interview on 11/8/23 at 12:09 p.m., RN 1 (Registered Nurse) indicated the facility had been serving meals on styrofoam for a while now. The resident's meals should have been served on real dishes and real silverware. The clinical record for Resident B was reviewed on 11/8/23 at 9:29 a.m. The diagnoses included, but were not limited to, respiratory failure, muscle wasting of shoulders and hands, and weakness. A quarterly MDS (Minimum Data Set) assessment, dated 9/12/23, indicated Resident B was cognitively intact. 2. During an interview on 11/9/23 at 11:24 a.m., Resident C indicated his meals had been served on styrofoam and he didn't like it. When Resident C tried to eat his food out of the styrofoam containers, the food slipped out of the container very easily nor did Resident C use styrofoam at home. Resident C felt like the meals should have been served on regular dishes and real silverware instead of styrofoam containers and plastic silverware. The clinical record for Resident C was reviewed on 11/9/23 at 10:25 a.m. The diagnoses included, but were not limited to, respiratory failure, diabetes, and bipolar disorder. A quarterly MDS assessment, dated 10/19/23, indicated Resident C was cognitively intact. On 11/9/23 at 1:15 p.m., the Administrator provided a copy of an undated policy, titled Dignity, and indicated this was the current policy used by the facility. A review of the policy indicated only use plastic and styrofoam plates, cups, and utensils when extremely necessary with a documented rationale. This citation relates to Complaint IN00420983. 3.1-3(t)

Based on record review and interview the facility failed to ensure staff followed the plan of care for transferring a resident with a mechanical lift which resulted in a fractured right knee for 1 of 3 residents reviewed for transfers in a sample of 3. (Resident #B and certified nursing assistant (CNA) #1) The Isolated Actual Harm began on 1/28/16, when the facility failed to identify staff were not following the plan of care for transferring a resident who required the assistance of a mechanical lift. Resident #B was sent to the emergency roiagnom on [DATE], and was diagnosed with [REDACTED]. The audits are on-going and the facility will monitor 5 transfers daily for 4 weeks, then 2 resident transfers weekly for 5 months. They also inserviced staff on the Hoyer and stand-up lifts and where to find the transfer care information for each resident. The correction date was prior to the start of the survey and was therefore Past Noncompliance. Findings include: The clinical record for Resident #B was reviewed on 2/11/16 at 2:10 p.m. [DIAGNOSES REDACTED]. A care plan dated 8/28/15, indicated the resident required the assistance of 2 staff members for all transfers. An updated care plan on 10/20/15, indicated the resident required a Hoyer (mechanical lift) and assistance of 2 staff members for all transfers. The most recent Quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated the resident had a Brief Interview Mental Status (BIMS) score of 15 (cognition intact). A progress note dated 1/28/16 at 14:07 (2:07 p.m.), indicated the resident complained of increased knee pain during a transfer for a wound clinic appointment. An order was received for an X-ray and the results were negative. A progress note dated 1/29/16 at 6:40 a.m., indicated the resident complained of severe right knee pain during the night. Resident #B indicated to the nurse, she hurt her leg yesterday while being transferred on the stand-up lift. An order was received to send the resident out to the hospital emergency room for evaluation of right knee pain. A hospital CT (computerized axial tomography X-ray) scan dated 1/29/16, indicated the resident had a right knee fracture. An investigative statement dated 1/29/16 at 4:30 p.m., from CNA #1 indicated she transferred Resident #B using a stand-up lift instead of the Hoyer lift required, as indicated by the care plans. CNA #1 also indicated she always used the stand-up lift for this resident. During an interview with the Director of Nursing (DON) on 2/15/16 at 10:40 a.m., she indicated CNA #1 said she always transferred the resident with the stand-up lift. Additionally, the DON indicated the CNA was terminated. On 2/15/16 at 10:05 a.m., the Administrator provided the Mechanical Lift policy dated 7/1/11, and indicated the policy was the one currently being used by the facility. Review of the policy indicated, Guideline: It is the intent of the facility that Hoyer lifts are used to enable staff to lift and move a resident safely. . Procedure: . 13 . One staff member guides from behind chair and one in front as resident is being lowered into chair . The Isolated Actual Harm began on 1/28/16, and was corrected on 1/29/16. The facility identified other residents that required mechanical lift assistance and implemented a system to audit transfers. They also inserviced staff on the Hoyer and stand-up lifts and where to find the transfer care information for each resident. The correction date was prior to the start of the survey and was therefore Past Noncompliance. This Federal tag relates to Complaint IN 409. 3.1-45(a)(2)

Based on observation, record review, and interview, the facility failed to ensure 2 residents who entered the facility without pressure ulcers did not develop a pressure ulcer, in that a resident did not receive timely skin assessments/interventions and developed a Stage III pressure ulcer on his left ischium (hip area) (Resident #24), a resident admitted with redness to her sacrum did not receive timely assessments and interventions and developed an open area on her coccyx (Resident #75), and a resident admitted with a Stage III pressure ulcer did not receive wound assessments according to her plan of care and facility policy (Resident #62) for 3 of 4 residents who met the criteria for review of pressure ulcers. Findings include: 1. The closed clinical record of Resident #24 was reviewed on 1/4/16 at 2:05 p.m. [DIAGNOSES REDACTED]. Resident #24 was admitted to the facility on [DATE]. A care plan dated 7/23/15 and current through 10/22/15, indicated the resident had a potential for skin breakdown. Interventions included a pressure reducing pad in wheelchair, staff to observe skin condition with each care interaction, weekly skin assessment to be completed, and providing a pressure reducing mattress on the bed. On 1/6/15 at 11:00 a.m., the Administrator indicated a pressure reducing mattress was the standard mattress used by the facility for all residents, unless they required a mattress providing additional pressure relief. An admission Minimum Data Set (MDS) assessment, dated 8/4/15, indicated the resident required extensive physical assistance of 2+ staff for bed mobility, toileting and personal hygiene, was totally dependent on staff for transferring, had functional limitation in range of motion on both sides of upper and lower extremities, and did not have a pressure ulcer. A nursing admission record, dated 7/23/15, indicated he did not have a pressure ulcer. A nurse's note dated 7/23/15 at 10:30 p.m., indicated the resident said he needed an, air bed, because he had one at home. A nurse's note dated 7/24/15 at 3:23 p.m., indicated the resident again requested an air mattress. A nurses's note dated 7/24/15 at 1:53 a.m., indicated no open areas in the resident's skin were noted. A Weekly Skin Sheet assessment dated [DATE], indicated he did not have any open areas. The next reference to the resident's risk for developing a pressure ulcer was 8/14/15 (14 days later). A nurse's note dated 8/14/15 at 2:05 p.m., indicated the resident had an excoriated open area on his left gluteal fold measuring 3 centimeters (cm) x 2.5 cm x 0.5 cm. The resident's, excoriated area, was not evaluated by a wound nurse until 8/20/15 at 12:03 p.m. (6 days after the initial open area was noted). A Wound 3.2 Weekly Skin assessment dated [DATE], indicated the resident now had a Stage III pressure ulcer on his left ischium. A Stage III pressure ulcer involves full thickness skin loss and involves damage to subcutaneous tissue. On 1/4/16 at 4:45 p.m., the MDS (Minimum Data Set) coordinator indicated a low air loss mattress, as indicated by his care plan, was not provided to Resident #24 until 9/3/15. 2. The clinical record review for Resident #75 was completed on 12/31/15 at 1:54 p.m. [DIAGNOSES REDACTED]. a) A review of an admission assessment dated [DATE], indicated Resident #75 had redness to the sacral area. The sacrum is a bone formed from the fusion of spinal vertebra between the coccyx and lumbar regions. A nurses note dated 8/4/15 at 13:17, indicated .New order for skin barrier to o/a (open area) on coccyx) . No further wound assessment documentation was found in the clinical record between 8/4/15 through 8/11/15, when Resident #75 discharged to hospital. An Admission/Re-admission assessment dated [DATE], indicated resident had an open area to coccyx, measuring 5.0 centimeters long by 5.0 centimeters wide by 0.5 centimeters deep. No further wound assessment documentation was found in Resident #75's clinical record. On 12/31/15 at 10:04 a.m., the DON provided a policy titled, Pressure Ulcer Assessment and Staging, dated 7/1/11, and indicated it was the current policy used by the facility. The policy indicated, .When the Charge Nurse is aware of skin breakdown .Document site, stage, size, depth, drainage, color, odor, prevention and treatment response .Documentation of decubitus must occur upon identification and at lease once a week. Assessment must include: a) Characteristics, (i.e. size, shape, depth, color, presence of granulation tissue, necrotic tissue) On 1/4/16 at 11:35 a.m., the DON indicated there was no other wound assessment documentation available in the clinical record for Resident #75. b) A dietary note dated 8/25/15 at 09:37, indicated Resident #75 was to receive cottage cheese and fortified pudding twice a day to aid in healing resident's wound. Point of Care meal consumptions documentation was reviewed for August and September, 2015. Documentation included date, meal time, and a number indicating the amount eaten (0 indicated 0-25% meal consumption, 1 indicated 26%-50% meal consumption, 2 indicated 51%-75% meal consumption, 3 indicated 76%-100% meal consumption). A dietary note dated 8/24/15, indicated Resident #75's average meal intake consumption is 50-75%. A review of facility meal intake documentation for September 1 - September 27, 2015, indicated Resident #75 consumed 26%-50% of 12 meals and 51%-75% of 24 meals. During an interview on 1/4/15 at 11:35 a.m., the DON indicated there is no separate documentation to monitor the consumption of cottage cheese and fortified pudding interventions in place to aid in wound healing. The DON indicated they are included in the overall meal consumption documentation. 3. The clinical record review for Resident #62 was completed on 12/30/15 at 2:30 p.m. [DIAGNOSES REDACTED]. Resident #62 admitted to the facility on [DATE]. An assessment of Resident #62's skin, dated 9/24/15, indicated Resident #62 admitted to facility with a stage 3 pressure ulcer wound to right ischium. A review of Resident #62's clinical record, lacked documentation of right ischium wound assessments between 9/25/15 to 10/7/15, and 10/15 to 11/1/15. Weekly skin reports dated 10/5/15, 10/17/15, 10/31/15, indicated Resident #62 had a wound to right ischium, but lacked an assessment of the wound. A review of nursing progress notes from 9/25/15 through 11/2/15, lacked documentation of right ischium wound assessment. On 1/5/16 at 1:45 p.m., Resident #62's unstageable right ischium wound was observed to be consistent with wound clinic documentation. During an interview on 1/6/16 at 10:26 a.m., the Director of Nursing (DON) indicated there were no other wound assessments between 9/25/15 to 10/7/15 and 10/15-11/1/15, in the clinical record for Resident #62. On 12/31/15 at 10:04 a.m., the DON provided a policy titled, Pressure Ulcer Assessment and Staging, dated 7/1/11, and indicated it was the current policy used by the facility. The policy indicated, .Documentation of decubitus must occur upon identification and at lease once a week. Assessment must include: a) Characteristics, (i.e. size, shape, depth, color, presence of granulation tissue, necrotic tissue) 3.1-40(a)(1) 3.1-40(a)(2)

Based on interview and record review, the facility failed to ensure a resident was free from a significant medication error in that Resident #A had not been correctly identified by the nurse and was given another resident's evening medication in addition to Resident #A's evening medication which resulted in an overdose of medication and overnight hospital stay for 1 of 4 residents reviewed for medication administration. (Resident #A) Findings include: On 12/14/15 at 11:02 a.m., an interview with Resident #A indicated the following: On 10/25/15, at approximately 6:00 p.m., Resident #A was experiencing some pain and used the call light to get assistance from her nurse to request pain medication. No staff responded to the call light so Resident #A went to the nurses station to find her nurse to get the pain medication. Registered Nurse (RN) #1 indicated she would give Resident #A the pain medication and her evening medications. Resident #A took the medication as given and returned to her room. The October 25, 2015 at 6:00 p.m., Medication Administration Record [REDACTED] [MEDICATION NAME] 600 mg (milligram), montalukast sodium 10 mg , ropinirole hci 2 mg, [MEDICATION NAME] 40 mg, [MEDICATION NAME] hci 50 mg, [MEDICATION NAME] 5 mg, [MEDICATION NAME] inhaler, [MEDICATION NAME] 600-800 mg , [MEDICATION NAME] 12.5 mg, [MEDICATION NAME] 8.6- 50 mg, and 2 [MEDICATION NAME] 10-325 mg. Continued interview with Resident #A indicated at approximately 10:00 p.m., RN #1 entered Resident #A's room with a cup full of pills. At that time, Resident #A indicated to RN #1 that she had already given the evening medications. RN #1 indicated to Resident #A, those were pain pills. Resident #A looked in the medication cup and questioned the pills. That was too many pills. RN #1 insisted those were the correct pills and sometimes medications can look different, because they come from different manufacturers. Resident #A took the medication. I did not want the nurse to chart I refused. RN #1 exited the room. After taking the medication and throwing the medication cup in the trash, Resident #A noticed another resident's name on the medication cup and immediately told a staff member the concern. Resident #A was told by staff the medication cup belonged to a resident across the hall. RN #1 returned to Resident #A's room and indicated Resident #A needed to go to sleep. 'The medication would not affect your heart medication.' Resident #A insisted on going to the hospital. Resident #A's clinical record was reviewed on 12/14/15 at 12:00 p.m. [DIAGNOSES REDACTED]. The admissions Minimum Data Set (MDS) assessment indicated Resident #A was interviewable and cognitively intact. Physician's order dated 10/25/15, indicated, Resident #A received the following scheduled medications: [REDACTED]. Resident #A's current physician's order did not include the following medications, which were given to Resident #A on 10/25/15 at approximately 10:00 p.m.: [MEDICATION NAME] ER (extended release)15 mg (milligram) a scheduled 2 narcotic used to control moderate to severe pain, [MEDICATION NAME] ER 60 mg a scheduled 2 narcotic used to control moderate to severe pain, [MEDICATION NAME] 0.5 mg a schedule 4 narcotic used to treat anxiety/panic attack, [MEDICATION NAME] 50 mg a schedule 4 controlled substance used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION], [MEDICATION NAME] 10 xs (times) 2, and atorvastatin (cholesterol). Nursing progress note dated 10/25/15 indicated, Resident sent to (local hospital) ER (emergency room ) for observation. Ambulance dispatch worksheet dated 10/25/15, indicated, chief complaint, MEDICATION admin (administration) ERROR. nature of dispatch Overdose. Resident #A's blood pressure at 22:14 (10:14 p.m.) was 188/139. A normal blood pressure was 120/80. emergency room nursing notes dated 10/25/15, indicated, Registered Nurse (RN) from (Name of Nursing home) called report, Pt (patient) was given [MEDICATION NAME] ER 15 mg (milligram) [MEDICATION NAME] ER 60 mg, [MEDICATION NAME] 0.5 mg, [MEDICATION NAME] 50 mg, [MEDICATION NAME] 10 xs (times) 2, and atorvastatin by mistake at 2200 (10:00 p.m.). Physician Assistant notes dated 10/25/15 indicated, . History, Ingestion, .(Resident #A) usually takes 2 [MEDICATION NAME] 10mg tablets, which she did take this evening. However, she was also given [MEDICATION NAME] IR (sic) 15 mg, [MEDICATION NAME] ER 60 mg, [MEDICATION NAME] 0.5 mg, and [MEDICATION NAME] 50 mg about 1 hour ago. She says she feels sleepy. Pain is currently controlled. Acute care hospital notes indicated Resident #A was kept overnight for observation due to the ingestion of medication. On 12/15/15 at 11:51 a.m., interview with Registered Nurse #1 indicated, on 10/25/15, around 9:30 p.m., second medication pass was being administered. RN #1 had written Resident #D's name on a medication cup, popped out the pills and proceeded down the hall to give Resident #D the medication. Upon walking down the hall RN #1 indicated there was a distraction and instead of entering Resident #D's room, RN #1 turned the wrong way and entered Resident #A's room. RN #1 indicated Resident #A had a question about one of the pills, but took the medication. RN #1 indicated after exiting the room and returning to the medication cart realized. I had given the wrong medication. I just didn't check the name on the cup. On 12/14/15 at 2:50 p.m., interview with the Director of Nursing (DON) indicated the only nursing note concerning the medication error was Resident #A was sent to hospital for observation. On 12/15/15 at 11:40 a.m., interview with the Director of Nursing indicated, RN #1 had been suspended after the medication error. She (RN #1) had incorrectly identified the resident (Resident #A). On 12/15/15 at 11:05 a.m., the Director of Nursing (DON) provided facility policy 5.1 DRUG ADMINISTRATION--GENERAL GUIDELINES dated June 19, 2012, and indicated the policy was the one currently used by the facility. The policy indicated, .2. Medications are administered in accordance with written orders of the attending physician.7. Residents are identified before medication is administered: check identification band, check photograph attached to medical record, . call resident by name, .SIX RIGHTS' FOR ADMINISTRATION OF MEDICATIONS 1. The right resident: .2. The right drug: . The Wolters Kluwer Nursing 2014 Drug Handbook, 34th edition, copyright 2015, indicated, . [MEDICATION NAME] hcl . for moderate to severe pain .Cautions . Use with caution in elderly .patients .[MEDICATION NAME] 0.5 mg a schedule 4 narcotic used to treat anxiety/panic attack, [MEDICATION NAME] 50 mg a schedule 4 controlled substance used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION]. This Federal tag relates to Complaint IN 473. 3.1-48(c)(2)

Based on record review and interview, the facility failed to ensure staff had proper training for the use of a mechanical lift that resulted in a fall from the lift with hospitalization and right and left leg fractures for 1 of 3 residents reviewed for falls and hospitalization s in a sample of 3 (Resident #B and CNA #1). Findings include: The clinical record for Resident #B was reviewed on 2/18/15 at 11:10 a.m. [DIAGNOSES REDACTED]. The resident's most current Minimum Data Set (MDS) assessment dated [DATE], indicated the BIMS (brief interview of mental status) score was 12 (moderate cognitive impairment). The resident was totally dependent with transfers and required the assistance of 2 staff members using the mechanical lift (device used to transfer residents from the bed to the chair or from the chair to the bed). An Incident Report dated 1/29/15 at 20:45 (8:45 p.m.), indicated a nurse was called to Resident #B's room because of a fall. The report indicated the resident stated, "I fell from the lift" and complained of hip and abdominal pain rated at 10/10 (pain scale 10 being the worst pain). The report also indicated the resident was transported to the hospital emergency room by ambulance at that time. A statement written by CNA #1 dated 1/29/15, indicated ... she was not aware the sling had six straps and was supposed to be crossed between the resident's legs during a transfer. A undated statement written by RN #2 indicated, ... the employee did not request assistance with transferring the resident according to the facility policy and the resident fell out of the sling onto the floor. RN #2 also indicated Resident #B stated, "she dropped me ..." A hospital discharge note dated 1/30/15, indicated Resident #B was diagnosed with [REDACTED]. During an interview with the Director of Nursing (DON) on 2/18/15 at 1:55 p.m., she indicated CNA was the only staff member in the room and there should have been 2. She also indicated CNA #1 was a new employee hired on 12/5/14. During an interview with the DON on 2/18/15 at 2:45 p.m., she indicated the facility was unable to locate CNA #1 skills checklist (document that indicated the employee could demonstrate proper use of the mechanical lift). The record lacked documentation of CNA #1 skills checklist was completed. On 2/19/15 at 9:30 a.m., the DON provided the Manual Lift guideline documentation dated 7/1/11, and indicated the guideline was the one currently being used by the facility. "Guideline: It is the intent of the facility that (manufacture name) lifts are used to enable staff to lift and move a resident safely ... ... 13. ... One staff member guides from behind chair and one in front as resident is being lowered into chair ..." This Federal tag relates to Complaints IN 403 and IN 239. 3.1-45(a)(1)

Based on observation, interview, and record review, the facility failed to ensure a resident was adequately supervised during smoking which resulted in a resident's electric wheelchair and blanket catching fire; the resident throwing himself out of his wheelchair; a gentleman pulling him to safety away from the fire; and a hospitalization for treatment of [REDACTED]. (Resident #B) Findings include: Initial tour of the facility was initiated on 12/29/10 at 10:10 a.m. with the Director of Nursing (DoN) present and smokers in the facility were observed, identified, and the DoN identified their mobility status. Faith hall had no smokers, Hope hall had 9 residents who smoked, and Love hall had 10 residents who smoked. Resident #B was identified as a smoker and as the person involved in the fire incident. Resident #B's clinical record was reviewed on 12/29/10 at 1:25 p.m. and indicated the resident was admitted to the facility on [DATE], was [AGE] years old, and had [DIAGNOSES REDACTED]. Nurse's notes dated 12/07/10 indicated a new smoking assessment was completed and discussed with the resident and it was explained to the resident due to the resident being wheelchair bound the resident would be a supervised smoker and at designated times. The resident voice understanding at that time. This entry was made by the Social Service Director (SSD). Nurse's notes dated 12/10/10 indicated the SSD spoke with Resident #B's mother and informed her the resident was assessed on 12/07/10 and the resident would have to be supervised while smoking and go out to smoke at designated times only. Interview with the Administrator on 12/29/10 at 10:38 a.m. indicated she had no reportables since the last survey except the incident of the fire which was entity self-reported. The Administrator explained due to the cold weather she had looked at the facility's smoking policy on 12/06/10 and the policy was reviewed with the residents on 12/06/10. Resident council meeting minutes were reviewed on 12/29/10 at 11 a.m. indicated the Social Service Director (SSD) was invited to the meeting on 11/17/10 to talk about the smoking policy. The minutes indicated the residents were not allowed to have smoking materials on their person. Interview with the Administrator on 12/29/10 at 10:38 a.m. indicated the following smoking policy was in place at the time of the fire incident: "Smoking Policy __________ (name of facility) has established a smoke free environment inside the facility. This smoke free indoor environment will be enforced. Upon admission all new residents will be informed that they will not be permitted to smoke in the facility and that smoking is only allowed at designated times and must be supervised. No residents are allowed to keep smoking materials including cigarettes, lighters, pipes, cigars etc. All smoking materials must be turned in at the nurses station to a nurse or to the Social Service Director. Smoking Stipulations * All smoking materials must be kept at the nurses station * Smoking is only permitted in the designated smoking area outside at the designated supervised smoking time * Residents must extinguish their cigarettes in the appropriate receptacle * No residents will be allowed to smoke while using oxygen as this creates a hazard to themselves and others' * Residents may go outside to smoke in the designated area with a responsible family member or visitor who must sign that resident out * A family member or visitor may supervise a resident who requires supervision after signing the resident out. One resident may not supervise another resident smoking * Residents who are deemed as unsafe will be required to wear a smoking apron during supervised smoking times. Smokers will be assessed by the Social Service Director or Director of Nursing to determine if the resident is a safe or unsafe smoker * Any resident who is deemed unsafe and refused to wear a smoking apron will not be allowed to smoke * Smoking times may be restricted in inclement weather. Non Compliance With Smoking Policy If a resident is noncompliant with the smoking policy this non compliance will be documented in the residents medical record. Any resident not complying with these smoking terms will lose their smoking privileges until the Social Service Director, Director of Nursing, Administrator and the resident meet and determine that the resident may resume their smoking privileges. If the non compliance occurs a second time the resident will be given a discharge notice from the facility for continued non compliance and disregard for the health and safety of others. I have read or have had read to me the smoking policy. I understand and agree to be compliant with this smoking policy and understand that failure to do so may result in loss of smoking privileges or discharge from the facility." The facility's investigation and 5 day follow-up report dated 12/17/10 indicated Resident #B who is [AGE] years old and alert and oriented times 3, moved himself outside the facility to smoke in the designated smoking area on Friday, December 10 th, 2010 at 11:30 p.m. Resident #B was observed by Resident #D in the smoking pavilion smoking a cigar. Resident #D and Resident #E were accompanied by staff member, RN #1 who had just ended her shift to go out to smoke. LPN #2 observed RN #1, Resident #D, and Resident #E re-entering the facility at approximately 11:40 p.m. as LPN #2 was walking to her car as her shift had ended. LPN #2 noticed Resident #B was sitting inside the smoking pavilion as she passed and asked Resident #B if he was going inside and Resident #B responded with a yes. LPN #2 did not note Resident #B to be smoking at this time. At approximately 12:15 a.m. on 12/11/10, the nursing staff noticed a man banging on the south exit/entrance door. Two employees started in the direction of the door to assist the gentleman when they noticed the gentleman assisting a resident across the sidewalk. Meanwhile, the employees noticed smoke coming from the outside smoking pavilion. A male employee obtained a fire extinguisher and continued outside to the smoking pavilion to extinguish the fire while the female employee alerted the other staff member to contact 911 and then attended to Resident #B. Interview with Resident #B explained he had moved himself outside of the building to the smoking pavilion. While in the smoking pavilion , Resident #B noticed his blanket had gotten caught around the left front wheel of his motorized wheelchair and while continuing to smoke Resident #B indicated he tried to move his electric wheelchair in an attempt to free the blanket at which time Resident #B realized his blanket had caught on fire. Resident #B explained he was able to get himself out and away from his wheelchair and the gentleman assisted him out of the pavilion. Resident #B was assessed and suffered no burns, but was transported to the hospital for precautionary measures due to being exposed to smoke. Resident #B's electric wheelchair was damaged during the incident, but there was no structural damage to the pavilion. Resident #B failed to follow the facility's smoking policy which required him to have supervision and not have smoking materials on his person. The physician and responsible party were notified and Resident #B's plan of care was reviewed. The current smoking policy was reviewed. Employees have been re-educated on the facility's smoking policy. Three identified employees were counseled for failure to follow facility policy. All residents who smoke have been identified and their care plans have been reviewed. All residents who smoke have received, and reviewed with a staff member, a copy of the current smoking policy. All doors were re-coded and set to alarm each time they open. All rooms were checked for smoking materials. Smokers identified as having the potential for non-compliance were placed on 15 minute checks. Interview with Resident #C on 12/29/10 at 11:25 a.m. indicated he used to be an independent smoker, but since the incident and re-assessment he is no longer independent. Resident #C indicated he had been smoking since 9 years old and that was why he came to this facility so he could smoke independently. Resident #C indicated he is not happy that he now has to wear a "bib" now as he did not before. Resident #C indicated he felt like he was treated like a little kid, but now if someone has materials they should not have, he would report them. Interview with Resident #B on 12/29/10 at 3:15 p.m. indicated his blanket got caught on his electric wheelchair and he thinks the friction when he was trying to attempt to free the blanket caused the fire. Resident #B indicated the fire started underneath the wheelchair by his legs and he threw himself out of the wheelchair onto the ground. Resident #B indicated a man passing by seen the flames and helped him. Resident #B indicated he breathed in a lot of smoke and was treated at the hospital for smoke inhalation. Resident #B indicated his electric wheelchair was brand new and only 2 weeks old. Interview with the SSD on 12/29/10 at 3:38 p.m. indicated the facility called her after the incident and she observed Resident #B's wheelchair and described it as crispy. The SSD indicated his blanket was recognizable. The SSD indicated she did inservices the morning of the incident, that afternoon, and into the evening on the smoking policy. The SSD indicated room searches were completed. The SSD indicated she had called family's updating them on the facility's current policy and the ones who were not reachable via phone were mailed. The SSD indicated she has inserviced staff, families, and residents. Interview with the Administrator on 2/29/10 at 10:38 a.m. indicated the facility has a new policy which corporate uses and it was put into place on 12/15/10 and staff were re-inserviced on the new policy. Review of the new smoking policy on 12/29/10 at 11:50 a.m. indicated some changes as the residents will be assessed quarterly and as needed to determine if a change in condition has occurred which may cause them to require supervision while smoking in the designated area outside, ensuring their safety and safety of others. Other changes were - supervised smokers will only be allowed to smoke outside with family members or visitors from 6 a.m. - 10 p.m. and independent smokers will be allowed unlimited smoking privileges in the designated smoking area from 6 a.m. - 10 p.m.. Independent smokers will not give cigarettes to supervised smokers as this has the potential to cause harm to themselves and others. Independent smokers will be allowed to take all their smoking supplies outside with them, but all supplies must be checked back in to the nurses' station upon entering the building. Facility doors are locked at 10 p.m. throughout the entire building. For security reasons, we do not encourage resident to use these exits after 10 p.m. This federal tag is related to Complaint IN 455. 3.1-45(a)(2)